Basic Information
Provider Information | |||||||||
NPI: | 1316948409 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HEWEL | ||||||||
FirstName: | KEITH | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1829 | ||||||||
Address2: |   | ||||||||
City: | COEUR D ALENE | ||||||||
State: | ID | ||||||||
PostalCode: | 838161829 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086663200 | ||||||||
FaxNumber: | 2086663397 | ||||||||
Practice Location | |||||||||
Address1: | 700 W IRONWOOD DR | ||||||||
Address2: | SUITE 110 | ||||||||
City: | COEUR D ALENE | ||||||||
State: | ID | ||||||||
PostalCode: | 838142656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086663200 | ||||||||
FaxNumber: | 2086663217 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2005 | ||||||||
LastUpdateDate: | 02/24/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | M-6804 | ID | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 1134798 | 01 | ID | CIGNA MEDICARE- RANI | OTHER | B1279 | 01 | ID | BC ID - PF | OTHER | P00099930 | 01 | ID | RR MEDICARE - RANI | OTHER | 003724900 | 05 | ID |   | MEDICAID | 300068472 | 01 | ID | RR MEDICARE | OTHER | 8218695 | 05 | WA |   | MEDICAID | DD537 | 01 | ID | BC ID - RANI | OTHER | DD545 | 01 | ID | BC ID - CDA | OTHER |